Tomorrow I’m doing a day-long workshop on suicide assessment and intervention at the University of Montana. The powerpoints are here: UM 2018 Suicide Workshop REV
Tomorrow I’m doing a day-long workshop on suicide assessment and intervention at the University of Montana. The powerpoints are here: UM 2018 Suicide Workshop REV
This might be the last call for you to sign up for the upcoming suicide workshop in Missoula. To help you lean toward attending, I’m doing something against my own advice. Below I’m listing the extremely exciting workshop Learning Objectives. Why is that against my own advice? Because usually I think Learning Objectives are obnoxiously boring. However, because I’m so into this topic, the LOs seem fascinating to me. . . this is just more evidence that I’ve lost my perspective and judgment. Anyhow, here they are:
2. Expand and Practice Suicide Assessment and Intervention Skills
3. Develop Your Self-Awareness and Refine Your Attitude Toward Suicide
Check out the registration form here:
Or, call 406-243-5252 to find out what you need to do to register for the Friday, April 6 workshop.
Hey Blog Readers.
For those of you who might be interested, I just published a new article on suicide assessment and interventions in the Journal of Health Service Psychology. The article title is, “Conversations about suicide: Strategies for detecting and assessing suicide risk.” The article is designed to help practitioners who work or may find themselves working with suicidal clients.
Here’s a link to the article: https://www.nationalregister.org/pub/the-national-register-report-pub/journal-of-health-service-psychology-winter-2018/conversations-about-suicide-strategies-for-detecting-and-assessing-suicide-risk/
Many professionals and media sources have proclaimed that suicide is a 100% preventable problem. Although I completely disagree with that message—and find it terribly offensive—I also believe that we should do what we can to prevent suicide.
Recently I was asked to write a journal article summarizing the conditions or dimensions that commonly contribute to suicide. To give you a flavor of these dimensions, below I’ve included brief descriptions of each one. However, I also want to emphasize that suicidologists and suicide researchers agree that death by suicide is nearly always unpredictable. Suicide is unpredictable despite the fact that, afterwards, many people and professionals will feel as though they should have “seen the signs” and done something more to prevent the death.
Knowing the following eight dimensions is useful when they’re used to enhance your compassion and capacity to collaborate with individual clients and persons. They’re not designed to be used as suicide risk factors or predictors.
Here are the eight dimensions.
Unbearable Psychological/Emotional Distress (Shneidman’s Psychache)
Shneidman (1985) originally identified “psychache” as the central psychological force leading to suicide. He defined psychache as negative emotions and psychological pain, referring to it as “the dark heart of suicide; no psychache, no suicide” (p. 200). In more modern patient-oriented language, psychache is aptly described as unbearable emotional distress. Unbearable distress can involve many factors, or center around one main trauma, loss, or other psychologically activating experiences; it may be accompanied by distinct cognitive, emotional, or physical symptoms.
Problem-Solving Impairment (Shneidman’s Mental Constriction)
Depression or low mood is commonly associated with problem-solving impairments. Originally, Shneidman called these impairments mental constriction, and defined them as “a pathological narrowing of the mind’s focus . . . which takes the form of seeing only two choices: either something painfully unsatisfactory or cessation” (1984, pp. 320–321). Researchers have reported support for Shneidman’s original ideas about mental constriction (Ghahramanlou-Holloway et al., 2012; Lau, Haigh, Christensen, Segal, & Taube-Schiff, 2012).
Agitation or Arousal (Shneidman’s Perturbation)
Agitation or arousal is consistently associated with death by suicide (Ribeiro, Silva, & Joiner, 2014). Shneidman (1985) originally used the term perturbation to refer to internal agitation that moves patients toward suicidal acts. When combined with high psychological distress and impaired problem-solving, agitation or arousal seems to push patients toward acting on suicide as a solution to their distress. Trauma, insomnia, drug use (including starting on a trial of serotonin-reuptake inhibitors), and many other factors can elevate agitation (Healy, 2009).
Thwarted Belongingness and Perceived Burdensomeness
Joiner (2005) developed an interpersonal theory of suicide. Part of his theory includes thwarted belongingness and perceived burdensomeness as contextual interpersonal factors linked to suicide. Thwarted belongingness involves unmet wishes for social connection. Perceived burdensomeness occurs when patients see themselves as flawed in ways that make them a burden to others.
Hopelessness is a broad cognitive variable related to problem-solving impairment and linked to elevated suicide risk (Hagan, Podlogar, Chu, & Joiner, 2015; Strosahl, Chiles, & Linehan, 1992). Hopelessness is the belief that whatever distressing life conditions might be present will never improve. In many cases, patients hold a hopeless view—even when a rational justification for hope exists.
Joiner (2005) and Klonsky and May (2015) have described how fear of death or aversion to physical pain is a natural suicide deterrent present in most individuals. However, at least two situations or patterns can desensitize patients to suicide and reduce natural suicide deterrence. First, some patients may be predisposed to high pain tolerance. This predisposition is likely biogenetic, as in blood-injury phobias (Klonsky & May, 2015). Second, patients may acquire, through desensitization, a numbness that reduces natural fears of pain and suicide. Chronic pain, self-mutilation, and other experiences can be desensitizing.
Suicide Plan or Intent
In and of itself, suicide ideation is a poor predictor of suicide. Nevertheless, ideation is an important marker to explore with patients; exploring ideation can lead to asking directly about whether patients have a suicide plan. Suicide plans may or may not be associated with suicide intent. Some patients will keep a potential suicide plan on reserve, just in case their psychological pain grows unbearable. These patients do not intend to die by suicide, but they want the option and sometimes they have thought through the method(s) they might employ.
Access to a lethal means is a situational dimension that substantially contributes to suicide risk. Firearms are far and away the most lethal suicide method. Specifically, Swanson, Bonnie, and Appelbaum (2015) reported that firearms result in an 84% case fatality rate. Although firearms can quickly become a politicized issue in the U.S., researchers have repeatedly found that access to firearms greatly magnifies suicide risk (Anestis & Houtsma, 2017).
From 13 Reasons Why, to Chris Cornell’s recent death, issues pertaining to suicide have been in our face this month. This is no surprise. May (late spring in the Northern hemisphere) is nearly always the month with the highest suicide rates.
That’s why right now is an excellent time for some straight talk about suicide.
Suicide is an emotionally triggering topic that’s notoriously difficult to talk or write about. Most of us know people who have been suicidal. Some of us know people who have died by suicide. Still others who read this may be having suicidal thoughts in this moment, or may have made suicide attempts in the past. Talking and writing about suicide is unpleasant, but necessary.
Because suicide is difficult to talk about, myths and misconceptions flourish. Not talking (or writing) about suicide also makes it harder to keep tabs on the latest research. Sometimes, leading professional journals neglect publishing new articles on suicide for a decade or more. This brings me to my purpose. To bust a few stubborn suicide-related myths and provide a glimpse at recent research on suicide prevention.
Let’s begin with now.
It’s a beautiful green spring in Montana with brilliant white snow in the mountains. Despite this beauty and brilliance, suicide rates rise in the spring and early summer and drop in fall and winter. Most people think the opposite is true, but every year, late spring and early summer bring the highest rates. Why? There are theories, but unfortunately, “we don’t know” is the answer to this and many questions related to suicide. I’m starting with this misconception to illustrate how easy it is to get the even the simplest facts related to suicide completely wrong.
One of the most insidious and unhealthy myths about suicide is the promotion of the idea that suicidal thoughts and impulses represent deviance or indicate the presence of a mental disorder. Once again, although many think it so, this idea is also untrue. Suicidal thoughts are a normal and natural response to psychological distress and misery. Social disconnection (relationship break-ups, death of a loved one, or other relationship problems) also can trigger suicidal thoughts in so-called “normal” people.
Our entire culture needs to stop classifying suicidal thoughts as automatic deviance. At one point or another, most people contemplate suicide, at least briefly. That fact pretty much blows the whole idea of suicidal thoughts as deviance right out of the metaphorical water.
Suicidal thoughts can be associated with specific mental disorders, but they are not, in and of themselves, signs of a mental disorder. In a recent large scale study, it was reported that mental disorders and suicidal thoughts weren’t useful in determining which individuals would eventually make suicide attempts.
Believing that suicidal thoughts represent a mental disorder isn’t just untrue, it’s also unhelpful. People who are suicidal, don’t need the public or professionals to make them feel worse by implying that their suicidal thoughts represent some form of illness.
Another surprising research finding is that, in general, suicide warning signs and suicide risk factors are unhelpful. This is true despite the fact that following a death by suicide, one of the first messages you’ll hear in the media is how important it is to watch for specific suicide warning signs. Unfortunately, like many things related to suicide, this is both good and bad advice. It’s good advice in that it’s always important to notice when friends, family, coworkers, and strangers are in distress and to do what we can to be comforting. But it’s also bad advice. Pointing the public or professionals toward warning signs implies that scientifically-based warning signs exist. They don’t.
There’s no science that supports the usefulness of warning signs or risk factors. This may seem discouraging, but it shouldn’t, because it leads to ONE BIG EXCELLENT CONCLUSION. That is, we should all try to offer support, empathy, and compassion to everyone. The take-home message is, don’t wait to encounter a suicidal person to unleash your kind and compassionate side. You should be leading with that. All. The. Time.
Chew on this idea for a moment. We’re stuck. If we’re interested in suicide prevention (or in having healthy relationships), our best default response is to treat everyone with kindness, respect, and empathy. I understand that’s impossible and I understand that you may think there are some exceptions to universal compassion. But we should try to lead with kindness, respect, and empathy anyway.
A good thing about having a general philosophy of kindness and compassion is that it helps suicidal people trust you. It will be harder for them to conclude, “This person is just being nice because I’m suicidal.” Instead, you’ll be treating everyone with kindness and empathy simply because that’s the sort of world you’re creating around you.
Another common suicide myth is that asking about suicide might somehow put the idea of suicide into someone’s head. Not true. Most people who are suicidal feel relieved and appreciative if you ask them about it in a nonjudgmental way. And, if you ask someone and they aren’t suicidal, well, the point is that people are highly resilient. They’re not so fragile that posing a short inquiry about suicide suddenly becomes life threatening. The other point is that you should ask with kindness and compassion. Even better, you should normalize the question by saying something like, “It’s not unusual for someone in your situation to have thoughts about suicide. I’m wondering if you’ve been having suicidal thoughts?” Making a statement that normalizes (rather than pathologizes) suicidal thoughts can make it easier to for people to talk more openly . . . and when people who are suicidal are talking openly, it will be easier for you to be helpful.
As if it weren’t already hard enough, another thing that’s especially complex is that when people are contemplating suicide, they often have strong negative reactions to infringements on their personal freedoms. This is partly why telling someone, you shouldn’t or can’t choose suicide, is a bad idea. Well-meaning helpers who push people too hard away from suicidal thoughts and toward embracing life can come across as “not understanding.” This could trigger an oppositional response. The person you want to help might either stop talking about it (but keep thinking about it) or feel an urge to oppose all suicide prevention or intervention efforts.
It’s not unusual for suicidal people to feel interpersonally isolated, disconnected, or as if they’re a burden to family, friends, and society. This makes connecting with them all the more important. It’s unfortunate, but people experiencing depression can be rather irritable or unappreciative of your efforts to listen and help. When you express concern, they might say something nasty in response. If so, let go of your needs for feeling appreciated; listen and be supportive anyway.
People who are suicidal can have difficulty problem-solving in a way that reflects hopefulness. Who wouldn’t have trouble being optimistic after experiencing repeated misery? This is why it’s important to problem-solve WITH people who are suicidal. Don’t usurp their control; lend another perspective. Part of this perspective might be the simple message that suicide is always an alternative, but that it’s important to wait and try as many other alternatives as possible.
Often, the response to your problem-solving efforts will be something like, “I’ve tried everything and nothing helps.” Again, we need to understand that when someone is suicidal, this is how it feels! At this point, acknowledge that right now it feels like nothing could possibly help. But at the same time, it’s okay to say things like, “I want you to live.”
If you’re problem-solving with someone who is suicidal, it’s also important to be persistent. Try saying something like, “Let’s make a list of everything you’ve tried, starting with whatever was the worst and most unhelpful idea ever.” Starting with what was unhelpful can resonate with the person’s pessimistic mood and help you identify something that’s at least not the worst option on the planet.
Chris Cornell’s recent death by suicide is a reminder of how specific medications can sometimes increase an individual’s agitation and/or suicidal thoughts. He was taking Ativan (Lorazepam). Ativan is a benzodiazepine (like Xanax and Valium). IMHO (and the science supports this), benzos are very bad medications to use for anything other than very short-term treatment. The bottom line is that sometimes (not always) psychiatric medications are not a part of the suicide solution and can become part of the suicide problem.
Among other things, Thirteen Reasons Why is a reminder of how easy it is for people to feel tremendously guilty when someone dies by suicide. Twenty-six years later, I still feel guilt over the death of a boy with whom I was working. Was it my fault? Absolutely not. Do I still feel bad? Absolutely yes.
Death by suicide is a tragedy. I’m tempted to say that it’s always a tragedy, but I recognize that when it comes to humans and humanity, using the terms always and never is dicey.
Some individuals are living with what they experience as intolerable physical, psychological, or emotional suffering. For their loved ones it’s likely still a tragedy when they die by suicide, but is it a tragedy for them? It’s hard to rule out the possibility that death by suicide may represent solace for them.
Suicide is a very personal option on the palette of human choice. For example, I want people to live. I want to help them reduce their psychological pain, make positive relationship connections, and re-engage in activities they find meaningful. But even so, sometimes suicide happens anyway. This is deeply painful and the guilt can be enormous. If someone close to you dies by suicide or you’re feeling affected by any suicide-related event, please find someone to talk with. One of my former clients once said, “The mind is a terrible place . . . to go alone.” Find someone you can trust and share any dark thoughts you might be having. Deal with it. Don’t let your guilt and angst simmer.
To summarize, suicide rates are highest right now. Does that mean we can relax later? Of course not. Suicide risk factors and warning signs are mostly useless and so we should treat people with respect and compassion all the time. When needed, we should ask the suicide question directly and with a spirit of non-judgmental normality. When possible, we should help people with suicidal thoughts identify options that might move them toward feeling better, while acknowledging that suicide is an option. We need to remember that sometimes medications can make suicidality worse. Perfect prevention is impossible. Suicide may happen despite our best efforts. Dealing with guilt over a suicide takes time and requires support.
No one will be completely happy with the ideas I’ve written here. That’s good. Individual reactions to suicide issues are unique. If you want to argue with or improve on these ideas, feel free to engage in the conversation. Using an attitude of kindness and respect, let’s keep talking about suicide. Right now, that’s the best solution we have to our suicide problem. In fact, it may be the best solution we’ll ever have.
To check out my recent professional journal article in Professional Psychology, click here: SF and Shaw Suicide 2017
Nearly everyone agrees that asking clients directly about suicide is the right thing. However, because every client situation is unique, there are also many different strategies for asking about suicide. In this short excerpt from Clinical Interviewing, we discuss how to bring up suicide using information from outside of the counseling or assessment session.
Using Outside Information to initiate Risk and Protective Factor Assessment
Outside of the formal suicide assessment interview, three main sources of information can be used to initiate a discussion with clients about suicide risk and protective factors:
If available, your client’s previous medical or mental health (med-psych) records are a quick and efficient source for client risk and protective factor information. Many risk factors listed in this chapter won’t be in your client’s records, but you should look closely for factors, such as: (a) previous suicide ideation and attempts; (b) a history of a depression diagnosis; and (c) familial suicide. After your standard intake interviewing opening and rapport building, you can use the records to broach these issues.
I saw in your records that you attempted suicide back in 2012. Could you tell me what was going on in your life back then to trigger that attempt?
When exploring previous suicide attempts, it’s important to do so in a constructive manner that can contribute to treatment (see Case Example 10.2). Using psychoeducation to explain to clients why you’re asking about the past helps frame and facilitate the process.
The reason I’m asking about your previous suicide attempt is because the latest research indicates that the more we know about the specific stresses that triggered a past attempt, the better we can work together to help you cope with that stress now and in the future.
Don’t forget to balance your questioning about previous suicide attempts with a focus on the positive.
Often, after a suicide attempt, people say they discovered some new strengths or resources or specific people who were especially helpful. How about for you? Did you have anything positive you discovered in the time after your suicide attempt.
It may be difficult to identify protective factors in your client’s med-psych records. However, if you find evidence of protective factors or personal strengths, you should bring them up in the appropriate context during a suicide assessment interview. For example, when interviewing a client who’s talking about despair associated with a current depressive episode, you might say something like:
I noticed in your records that you had a similar time a couple years ago when you were feeling very down and discouraged. And, according to your therapist back then, you worked very hard and managed to climb back up out of that depressing place. What worked for you back then?
Strive to use information from your clients’ records collaboratively. As illustrated, you can use the information to broach delicate issues (both positive and negative).
Traditionally, previous suicide attempts are considered one of the strongest predictors of future suicidal behaviors. However, as with all risk factors, previous attempts should be considered within the idiosyncratic context of each individual client. Case example 10.2 provides a glimpse of a case where a previous attempt ends up serving as a protective factor, rather than a risk factor.
Case Example 10.2
Exploring Previous Attempts as a Method for Understanding Client Stressors and Coping Strategies
Exploring previous suicide attempts is an assessment process. It can illuminate past stressors, but it’s equally useful for helping clients articulate past, present, and future coping responses.
Therapist: You wrote on your intake form that you attempted suicide about a year and a half ago. Can you tell me a bit about that?
Client: Right. I shot myself in the head. It’s obvious. You can see the scar right here.
Therapist: What was happening in your life that brought you to that point?
Client: I was getting bullied in school. I hated my step-father. Life was shit, so one day after school I took the pistol out of my mom’s room, aimed at my head and shot.
Therapist: What happened then?
Client: I woke up in the hospital with a bad fucking headache. And then there was rehab. It was a long road, but here I am.
Therapist: Right. Here you are. What do you make of that?
Client: I’m lucky. I’m bad at suicide. I don’t know. I suppose I took it to mean that I’m supposed to be alive.
Therapist: Have you had any thoughts about suicide recently?
Client: Nope. Nada. Not one.
Therapist: I guess from what you said that getting bullied or having family issues could still be hard for you. How do you cope with that now?
Client: I’ve got some friends. I’ve got my sister. I talk to them. You know, after you do what I did, you find out who really cares about you. Now I know.